Healthcare Provider Details

I. General information

NPI: 1447675665
Provider Name (Legal Business Name): MICHELLE WADSWORTH LPN
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 02/25/2014
Last Update Date: 02/25/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1785 N. IDAHO RD.
APACHE JUNCTION AZ
85119
US

IV. Provider business mailing address

30474 N REBECCA LN
SAN TAN VALLEY AZ
85143-4626
US

V. Phone/Fax

Practice location:
  • Phone: 480-677-7500
  • Fax: 480-982-1708
Mailing address:
  • Phone: 480-677-7500
  • Fax: 480-982-1708

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code376K00000X
TaxonomyNurse's Aide
License Number860951340
License Number StateAZ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: